Insights from the Defining Issues Test on Moral Reasoning Competencies Development in Community Pharmacists

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INTRODUCTION

Research show that higher levels of moral reasoning competencies, as measured by a survey form of psychometric measure known as the Defining Issues Test (DIT2), increase the probability that health care professionals will make decisions in the patient's best interests and/or report errors. (1-4) Supported by Neo-Kohlbergian theory, known validity criteria for the DIT2 conclude that scores increase with age and after engagement with profession-specific educational interventions. (1,5-7) However, research by Latif and Berger indicates that community pharmacists are a rare exception to the expectation that moral reasoning scores increase with age. (8,9) Neo-Kohlbergian theory proposes that identified deficits in moral reasoning might be addressed by engagement with educational interventions appropriate to the context in which community pharmacists practice pharmacy. (1,2,10) The objective of this study was to investigate whether an educational intervention incorporating peer discussion surrounding profession-specific dilemmas affected the development of moral reasoning competencies in community pharmacists working in Ireland.

Moral reasoning is concerned with the cognitive or thinking processes that individuals go through to arrive at a decision when faced with a dilemma. (1) Consistent with Kohlberg's theory of cognitive moral development, (1,11) Neo-Kohlbergian theory proposed that "an individual processes or interprets experience according to organising, conceptual structures in the mind that develop from and are influenced by experience." (12) In order to reason through a dilemma, these conceptual structures, referred to as "schemas," activate automatically without awareness. However, whereas Kohlberg's stages are generally defined in terms of cognitive operations, Neo-Kohlbergian (meta) schemas represent a network of knowledge that is organized around life events and these schemas exist to help individuals understand new information based on previous experience. Neo-Kohlbergian schema theory proposes that schemas are highly contextual and that an individual may default to different schemas depending on the presenting dilemma. (1,5,6)

In context, professional dilemma situations occur where a pharmacist is faced with two or more action options that are individually convincing, mutually exclusive and jointly demanding but noneofwhichisideal and all of which might be questioned by peers if subjected to external scrutiny. (1,13,14) Activation of 'reasoning' depends on an individual having acquired the competencies to identify the ethical concepts that arein tensiontocreateadilemma, what actions mightbejustifiable, and how others might be affected by the behavior implied by each action option. (1,8) When decision-making through dilemmas, a professional will first access "surface" level guidelines provided by rules, codes and norms governing practice of the profession and, where clear guidance is not evident, "intermediate" or profession-specific concepts will then be considered. (1,10,12,15) Only where the answer to "what should be done?" is not clear, will the individual default to his/her "bedrock" schema. (1,6,16) A morally defensible outcome is the objective of the reasoning process.

The conduct of community pharmacists in Ireland, and the pharmacies in which they work, are regulated by the Pharmaceutical Society of Ireland (PSI). (17,18) Patient counselling by pharmacists is a legal requirement in Ireland, both when dispensing prescriptions and when advising with respect to over-the-counter medicines, but patients have an expectation that an appointment will not be required. (18,19) Community pharmacists do not generally have pharmacist colleagues at the pharmacy for most of their working hours, indicating that isolation and a lack of peer interaction should be of concern. (19,20,21) Recent research highlight many potential sources of dilemmas, both personal to and external to pharmacists. …